The COVID Mothers Study: How ABM’s Worldwide Network of Physicians Collaborated on Urgent Research

By Melissa Bartick, MD, MS, FABM

This week, the results of the COVID Mothers Study were published in Breastfeeding Medicine, providing more evidence that it may be safe to keep mothers and newborns together and, importantly, that separating them causes significant harm.  Indeed, as the authors point out, the “significantly low rate of [neonatal] hospitalization in the literature indicates it may be nearly impossible to demonstrate a clinical benefit from disrupting Baby-Friendly practices.”

Like other studies involving COVID-19, coordinating and launching this study had to be done quickly, for answers were urgently needed.  As the World Health Organization declared a pandemic on March 11, news stories appeared about infected mothers being forcibly separated from their infants with the rationale of protecting infants from infection, without evidence to support this practice, which violated existing quality standards of maternity care from the World Health Organization.  By the end of March, I, together with Dr. Lori Feldman-Winter, and Dr. Verónica Valdés had planned to gather such evidence. Lori and I had known one another for many years and had collaborated before, and we both met Verónica when she volunteered to help us after I sent out an email to the ABM membership.  Lori and I are Americans; Verónica is Chilean. We met and planned out a study using a survey, initially thinking we would quickly and easily get a large number of respondents by recruiting from social media platforms. Lori was also able to recruit statistical support (Dr. John Gaughan, PhD) and medical student manpower with social media expertise (Nikhil Bhana, B.S.) from her university.

We took full advantage of ABM’s internal communications networks to help us line up people who could translate and distribute the survey. Word of the study spread around the world. Having heard of the study through an Italian ABM member, we were thrilled to be approached by Angela Giusti, PhD of the Italian National Institute of Health (ISS) and Elise Chapin, MEd of the Italian National Committee for UNICEF, and they joined our team. Not long afterward, Dr. Maite Hernández-Aguilar, an ABM member, joined us and became instrumental in getting the survey around Spain, where cases numbers were very high.  Other ABM members in Germany (Dr. Elien Rouw) and Saudi Arabia (Dr. Fouzia AlHreashy) came forward, and still other members led us to contacts that helped with translation and recruitment in Brazil and other parts of Latin America, as well as Asia. This is how we came to meet nursing professor Elysângela Dittz Duarte, RN, PhD of Brazil, an important member of the research team. 

When it became clear that there were not nearly as many birthing women with histories of active COVID as the news led us to believe, we relied on our networks of doctors and their colleagues, including midwives and other health professionals, to get the survey to patients they knew.  We engaged Lucia Jenkins, RN, IBCLC of Baby Café USA to send the survey out immediately via social media to her network of 158 breastfeeding support sites in 28 U.S. States, expanding geographical reach. We are able to engage many American ABM members, including those who worked in COVID “hot spots,” to directly reach their patients. Together, our total sample size of 357 infants is one of the largest to date for a single study, and the neonatal subset of 129 infants, with 84 SARS-CoV-2+ mothers, is among one of the larger sizes for a COVID study.

We could not have done this study without the amazing network that ABM provided, as well as many other people we knew or got to know around the world.  We are grateful to all of them, and to the mothers who took the time to answer our survey.

ABM Candid Conversations: A Virtual Interview with Protocol Authors Helen Johnson, MD and Katrina Mitchell, MD IBCLC

ABM is excited to launch the beginning of our Candid Conversations series, featuring ABM members and their various initiatives within the Academy as well as their professional lives. This week, ABM sat down virtually with Helen Johnson, MD and Katrina Mitchell, MD IBCLC, two authors of our most recent protocol Breast Cancer and Breastfeeding, to discuss how they became interested in breastfeeding medicine, what lead them to creating their protocol, and what shifts they’ve seen in practice over the last year with the current health crisis.

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  Katrina Mitchell, MD IBCLC

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  Helen Johnson, MD

Q: Please introduce yourself and provide any background or work information you’d like shared.

HJ: I am a native of Tampa, Florida and a graduate of Brown University’s Program in Liberal Medical Education.  I am currently in my fourth year of general surgery residency at East Carolina University/Vidant Medical Center in Greenville, North Carolina.  After residency I plan to pursue fellowship training in breast surgical oncology, and am currently working towards IBCLC certification.  My goal is to be able to provide high-quality care for patients with any breast condition, whether benign or malignant, and/or occurring during unique periods such as pregnancy or lactation.  I am passionate about research and evidence-based medicine, and hope to contribute to the advancement of scientific and medical knowledge related to breast disease. 

KM: I’m a breast surgeon and lactation consultant in Santa Barbara, California.  My practice focuses on the operative management of breast cancer, but I also care for breastfeeding dyads with a variety of lactation-related questions and concerns.

Q: How did you discover/enter the world of breastfeeding medicine? 

HJ: I experienced challenges breastfeeding my children.  When I sought medical evaluation for a breast condition, I was shocked by the fragmentation of care.  I was able to receive timely, helpful support from a lactation consultant, but it was much more difficult to find a clinician with prescribing privileges who was knowledgeable about lactation.  A colleague encouraged me to join the Facebook group Doctor Mothers Interested in Lactation Knowledge (“Dr MILK”), where I learned a great deal about breastfeeding from other physicians.  It was through Dr MILK that I first learned about ABM and the field of breastfeeding medicine.  I was so pleased to learn that there is a field devoted to breastfeeding medicine including care of the lactating breast, as I want to be able to help any patient with any breast concern. 

KM: During my breast surgical oncology fellowship in Houston, Pamela Berens was my breastfeeding medicine physician after the birth of my son.  She introduced me to the ABM, and my son and I attended our first conference in Portugal when he was 7 months old.

Q: How has being a member of ABM contributed towards your profession/life? 

HJ: Contributing to ABM protocols has been such a rewarding experience.  I have gained a deeper appreciation for the strength of the evidence for specific recommendations, and the process of developing societal guidelines.  I have especially enjoyed collaborating with other physicians who are passionate about breastfeeding medicine.  Through these collaborations, I have cultivated both professional connections and meaningful friendships.  

KM: The collaborative multidisciplinary aspect of ABM has opened an entirely new dimension in my professional and personal life.  I have developed a much more complex understanding of breast biology and pathophysiology than I ever knew as a breast surgeon alone.  I also have learned a great deal about pediatrics and the peripartum care of women, including the mental health challenges many patients experience. I have been so fortunate to have multiple mentors in breastfeeding medicine from different specialties, and I continue to learn something new each day.  I feel like I have completed a second residency in breastfeeding medicine!

Q: What lead you to identifying the topic you chose for the Protocol?

HJ: As a surgical resident who plans to practice breast surgery, I have a strong professional interest in the intersection between breast cancer and breastfeeding.  Little is taught about lactation in medical school or surgical training, yet breast surgeons and other physicians are entrusted with caring for breastfeeding patients with a current or past history of breast cancer.  As a moderator for Dr MILK, I read countless questions from other physicians about breast cancer screening, breast cancer treatment during breastfeeding, and breastfeeding among breast cancer survivors.  My impression was that physicians across multiple specialties would benefit from a practical, evidence-based resource to utilize when caring for this unique patient population.  

KM: Hyperlactation often results in complications that are surgical in nature – such as plugging, galactoceles, abscesses, and nipple conditions.  We thought it would be helpful to outline a standard approach to decreasing milk production in these patients to reduce maternal and infant complications of hyperlactation.  At the IABLE Ranch conference in 2019, we drafted this protocol and had great input from colleagues in different specialties who have practiced breastfeeding medicine in a variety of contexts.

The intersection of breastfeeding and breast cancer is a very challenging clinical scenario, and can be difficult for patients psychosocially as well.  Because we receive so many questions regarding this topic, we wanted to outline standard, evidence-based guidelines for the care of these patients.

Q: What difficulties has COVID-19 and its side effects (both in medicine and practice) presented to the implementation of your protocol? Or conversely, are there aspects of the current pandemic that have assisted it in any ways? 

HJ: In general, there have been many delays in routine cancer screening as a result of COVID-19, and sadly there has been an increase in the proportion of cancers which are advanced at presentation.  Many institutions had to halt non-emergent surgeries in order to divert resources towards care for COVID-19 patients, creating the need to utilize neoadjuvant treatment for breast cancers that were otherwise appropriate for up-front surgical therapy.

KM: Both cancer surgery and the care of breastfeeding dyads is not elective, so I have continued to see a large majority of patients in person, using standard precautions.  Telemedicine has allowed me to care for patients in other parts of our state, but there are significant limitations to evaluation via telemedicine.  The protocols have been very useful to share with colleagues during this time. 

Q: In your own life, what ways have you seen the pandemic change your daily working and life routines? 

KM: Remote learning is a real challenge for children and families.  We are very fortunate that my son meets state of California childcare guidelines for attending transitional kindergarten in person.  I am incredibly thankful to his school and teachers for what they do.  I’m concerned about the multitude of psychosocial and economic impacts of the shutdown, as well as patients avoiding care for other medical problems not related to Covid. 

Q: What are suggestions or tips you may have for physicians trying to implement your protocol, or more generally, support a breastfeeding parent at this time? 

HJ: I would remind readers that these protocols are living documents which are updated regularly, and that there remain many areas in breastfeeding medicine with limited evidence.  As such, I would encourage cross-disciplinary collaboration with other ABM members when seeking assistance for a challenging case as there may be more recent evidence to consider, and tips to be learned from the experiences of other breastfeeding medicine physicians.  

KM: Using standard precautions, I think it’s essential to evaluate patients in person whenever safely possible.

Q: Any additional thoughts? 

HJ: I would encourage surgeons who perform breast surgery to utilize ABM protocols and seriously consider joining ABM and learning more about breastfeeding medicine.

KM: Thank you to my ABM colleagues for their mentorship, friendship, and support.  Thank you to Helen Johnson for her friendship and incredible work ethic as a researcher and publisher.

New Protocol on Breast Cancer and Breastfeeding

New Rochelle, NY, June 10, 2020 — Managing women with breast cancer who are breastfeeding is a complex issue. The Academy of Breastfeeding Medicine presents new recommendations in the peer-reviewed journal Breastfeeding Medicine. Click here to read the article now.

“The aim of this new protocol is to guide clinicians in the delivery of optimal care of breastfeeding women as it relates to breast cancer, from screening to diagnosis, treatment, and survivorship,” state coauthors Helen Johnson, MD and Katrina Mitchell, MD.

It addresses the spectrum of care, including oncologic breast surgery, chemotherapy, and adjuvant and endocrine therapy. A section on breastfeeding women who have a previous history of breast cancer is included.

Arthur I. Eidelman, MD, Editor-in-Chief of Breastfeeding Medicine, states: “This protocol is a guide for mothers who are undergoing diagnosis and treatment for breast cancer. It emphasizes that they do not have to categorically give up on their nurturing role as breastfeeding moms.”

Breast cancer is the most common malignancy in women worldwide. One in 20 women will develop breast cancer in their lifetime.

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About the Journal
Breastfeeding Medicine, the official journal of the Academy of Breastfeeding Medicine, is an authoritative, peer-reviewed, multidisciplinary journal published 12 times per year in print and online. The Journal publishes original scientific papers, reviews, and case studies on a broad spectrum of topics in lactation medicine. It presents evidence-based research advances and explores the immediate and long-term outcomes of breastfeeding, including the epidemiologic, physiologic, and psychological benefits of breastfeeding. Tables of content and a sample issue may be viewed on the Breastfeeding Medicine website.

About the Academy of Breastfeeding Medicine
The Academy of Breastfeeding Medicine (ABM) is a worldwide organization of medical doctors dedicated to the promotion, protection, and support of breastfeeding. Our mission is to unite members of the various medical specialties with this common purpose. For more than 20 years, ABM has been bringing doctors together to provide evidence-based solutions to the challenges facing breastfeeding across the globe. A vast body of research has demonstrated significant nutritional, physiological, and psychological benefits for both mothers and children that last well beyond infancy. But while breastfeeding is the foundation of a lifetime of health and well-being, clinical practice lags behind scientific evidence. By building on our legacy of research into this field and sharing it with the broader medical community, we can overcome barriers, influence health policies, and change behaviors.

About the Publisher
Mary Ann Liebert, Inc., publishers is known for establishing authoritative peer-reviewed journals in many promising areas of science and biomedical research. A complete list of the firm’s 90 journals, books, and newsmagazines is available on the Mary Ann Liebert, Inc., publisher’s website.

Pregnant and Lactating Women with COVID-19: Scant Clinical Research

New Rochelle, NY, May 18, 2020 — Pregnant and breastfeeding women have been excluded from clinical trials of drugs to treat COVID-19, and as result, there is no safety data to inform clinical decisions. Such drugs include remdesivir according to a new article in the peer-reviewed journal Breastfeeding Medicine. Click here to read the article.

Since pregnant and lactating women are not included in clinical trials, little is known about whether the drug transfers into breast milk and reaches the infant’s circulation.

The lack of such data complicates a decision between giving lactating women a potentially life-saving drug and having them stop breastfeeding or risking any potential adverse effects of the drug on the infant, writes Alison Stuebe, MD, University of North Carolina School of Medicine and President of the Academy of Breastfeeding Medicine.

Suspending breastfeeding in mothers infected with COVID-19 could be detrimental because the infant is missing out on critical nutrients in human milk. Additionally, antibodies acquired from the mother may protect the infant against acquiring COVID-19.

“This quandary illustrates the consequences of longstanding policies to exclude pregnant and lactating women from clinical trials,” Stuebe says. “Rather than excluding pregnant and lactating women from research, we must protect them through research.”

Arthur I. Eidelman, MD, Editor-in-Chief of Breastfeeding Medicine, states: “Pregnant and breastfeeding women and their fetuses and infants cannot continue to be administrative orphans regarding new drug trials, and this situation warrants immediate correction.”

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About the Journal
Breastfeeding Medicine, the official journal of the Academy of Breastfeeding Medicine, is an authoritative, peer-reviewed, multidisciplinary journal published 12 times per year in print and online. The Journal publishes original scientific papers, reviews, and case studies on a broad spectrum of topics in lactation medicine. It presents evidence-based research advances and explores the immediate and long-term outcomes of breastfeeding, including the epidemiologic, physiologic, and psychological benefits of breastfeeding. Tables of content and a sample issue may be viewed on the Breastfeeding Medicine website.

About the Academy of Breastfeeding Medicine
The Academy of Breastfeeding Medicine (ABM) is a worldwide organization of medical doctors dedicated to the promotion, protection, and support of breastfeeding. Our mission is to unite members of the various medical specialties with this common purpose. For more than 20 years, ABM has been bringing doctors together to provide evidence-based solutions to the challenges facing breastfeeding across the globe. A vast body of research has demonstrated significant nutritional, physiological, and psychological benefits for both mothers and children that last well beyond infancy. But while breastfeeding is the foundation of a lifetime of health and well-being, clinical practice lags behind scientific evidence. By building on our legacy of research into this field and sharing it with the broader medical community, we can overcome barriers, influence health policies, and change behaviors.

About the Publisher
Mary Ann Liebert, Inc., publishers is known for establishing authoritative peer-reviewed journals in many promising areas of science and biomedical research. A complete list of the firm’s 90 journals, books, and newsmagazines is available on the Mary Ann Liebert, Inc., publisher’s website.

Should infants be separated from COVID-19-positive mothers?

MARY ANN LIEBERT, INC./GENETIC ENGINEERING NEWS

New Rochelle, NY, April 9, 2020–In a new commentary, Alison Stuebe, MD, President of the Academy of Breastfeeding Medicine, addresses the risks and benefits of separating infants from COVID-19-positive mothers following birth. Although multiple public health organizations recommended keeping mothers and infants together, the United States’ Centers for Disease Control and Prevention advises facilities to consider separating mothers and babies temporarily until the mother is no longer contagious, and recommends that the risks and benefits of temporary separation should be discussed with the mother by the healthcare team.

In her commentary, Dr. Stuebe, Professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine and distinguished professor in infant and young child feeding at the Carolina Global Breastfeeding Institute at the UNC Gillings School of Global Public Health, notes that there is no evidence to show that early separation of infants and mothers with suspected or confirmed COVID-19 improves outcomes. While separation may minimize the risk of transmission of the virus from mother to infant during the hospital stay, it has potential negative consequences for both mother and infant, according to the commentary published in Breastfeeding Medicine, the official journal of the Academy of Breastfeeding Medicine published by Mary Ann Liebert, Inc., publishers. Click here to read the protocol free on the Breastfeeding Medicine website.

Dr. Stuebe outlines several risks of separating mothers and infants in the hospital, which disrupts breastfeeding and skin-to-skin contact during the critical hours and days following birth. For example, infants who lack skin-to-skin contact with their mothers tend to have higher heart rates and respiratory rates and lower glucose levels. The separation also stresses the mother, which could make it more difficult for her to fight off the viral infection. In addition, separation interferes with the provision of maternal milk to the infant, which is important for the development of the infant’s immune system. Separation also disrupts breastfeeding, which puts the infant at increased risk of severe respiratory infections, including pneumonia and COVID-19.

“As we navigate the COVID-19 pandemic,” Stuebe writes, “I am hopeful that we can center mothers and babies and remember to first do no harm.”

Arthur I. Eidelman, MD, Editor-in-Chief of Breastfeeding Medicine, concurs that “there is no need or indication to categorically separate infants from COVID-19 suspect or positive mothers other than in circumstances wherein the mother’s medical condition precludes her caring for the infant. Feeding mothers’ own breast milk, either by nursing or by feeding of expressed milk, is OK and desired!”

About the Journal

Breastfeeding Medicine, the official journal of the Academy of Breastfeeding Medicine, is an authoritative, peer-reviewed, multidisciplinary journal published 10 times per year in print and online. The Journal publishes original scientific papers, reviews, and case studies on a broad spectrum of topics in lactation medicine. It presents evidence-based research advances and explores the immediate and long-term outcomes of breastfeeding, including the epidemiologic, physiologic, and psychological benefits of breastfeeding. Tables of content and a sample issue may be viewed on the Breastfeeding Medicine website.

About the Academy of Breastfeeding Medicine

The Academy of Breastfeeding Medicine (ABM) is a worldwide organization of medical doctors dedicated to the promotion, protection, and support of breastfeeding. Our mission is to unite members of the various medical specialties with this common purpose. For more than 20 years, ABM has been bringing doctors together to provide evidence-based solutions to the challenges facing breastfeeding across the globe. A vast body of research has demonstrated significant nutritional, physiological, and psychological benefits for both mothers and children that last well beyond infancy. But while breastfeeding is the foundation of a lifetime of health and well-being, clinical practice lags behind scientific evidence. By building on our legacy of research into this field and sharing it with the broader medical community, we can overcome barriers, influence health policies, and change behaviors.

About the Publisher

Mary Ann Liebert, Inc., publishers is a privately held, fully integrated media company known for establishing authoritative peer-reviewed journals in many promising areas of science and biomedical research, including Journal of Women’s Health, Childhood Obesity, and Pediatric Allergy, Immunology, and Pulmonology. Its biotechnology trade magazine, GEN (Genetic Engineering & Biotechnology News) was the first in its field and is today the industry’s most widely read publication worldwide. A complete list of the firm’s 90 journals, books, and newsmagazines is available on the Mary Ann Liebert, Inc., publisher’s website.

Academy of Breastfeeding Medicine Publishes New Bedsharing Guidelines

By Melissa Bartick, MD, MSc, FABM

The Academy of Breastfeeding Medicine has released its updated Bedsharing and Breastfeeding Protocol. The protocol presents evidence-based recommendations synthesized by an international collaboration of authorities on the topic who conducted a rigorous review of the literature.

Aimed at physicians and other health care professionals caring for families who have initiated breastfeeding, the protocol recognizes that bedsharing promotes breastfeeding.  In contrast to recommendations by some organizations, breastfeeding mothers and infants are not advised against bedsharing, as long as no hazardous circumstances exist. The protocol emphasizes that all parents should be educated on safe bedsharing, recognizing that bedsharing is very common, and when bedsharing is unplanned, it carries a higher risk of infant death than planned bedsharing.

Hazardous circumstances include sleeping with an adult on a sofa or armchair; sleeping next to an adult impaired by alcohol, medications, or illicit drugs; tobacco exposure; preterm birth; and never having initiated breastfeeding.

The ABM protocol takes a “risk minimization” approach, emphasizing a discussion of risks and benefits of bedsharing with parents. This type of approach is being increasingly adopted in countries such as the UK and Australia. “Having conversations about safe bedsharing is important for removing stigma around the topic and facilitating open and honest dialogue between parents and providers,” says Dr. Lori Feldman-Winter, Professor of Pediatrics at Cooper Medical School in Camden, New Jersey and one of protocol’s authors. Dr. Feldman-Winter serves as co-faculty chair on the National Action Partnership to Promote Safe Sleep (US), and she was also an author of the American Academy of Pediatrics’ 2016 protocol on safe sleep.

ABM was pleased and honored to collaborate with three of the world’s leading experts on this topic: anthropologists Helen Ball and James McKenna, and epidemiologist Peter Blair. Dr. Blair, Professor of Epidemiology and Biostatistics at the University of Bristol (UK) is chair of the International Society for the Study and Prevention of Perinatal and Infant Death (ISPID), and Dr. Ball, Professor of Anthropology at the University of Durham (UK), directs the Durham Infancy & Sleep Centre, as well as serving on ISPID Board. Dr. McKenna is known for his ground-breaking work from his Mother-Infant Sleep Lab at the University of Notre Dame (Indiana, USA). Dr. Kathleen Marinelli, Clinical Professor of Pediatrics at University of Connecticut Medical Center and co-author, was instrumental in arranging the participation of Drs. Blair, Ball and McKenna.

In creating the protocol, we rigorously reviewed all available evidence about risk. In addition, we put the current research and evidence into historical context, noting that solitary sleep and artificial feeding are related and were recent developments in human history. We noted that some marginalized and low-income populations have a higher rate of sudden infant death as well as a higher rate of artificial feeding, thus measures to increase breastfeeding and lower the exposure to hazardous circumstances in these populations are important.

“The welcome fall in unexpected deaths over recent decades has come about through risk reduction advice being closely aligned to the available published evidence. This protocol takes the same approach,” says Dr. Blair. 

Breastfeeding is important for safe infant sleep when bedsharing. “When bedsharing next to their mothers, breastfeeding infants sleep on their backs, and are naturally positioned away from pillows and objects that might obstruct their airways. Breastfeeding mothers form a protective position around their infant,” says Dr. Ball. Dr. Ball’s team provides detailed information for families through the Baby Sleep Information Source.

“Breastfeeding while bedsharing comprises a unique set of behaviors between mother and infant known as ‘breastsleeping,’ which also results in increased time breastfeeding compared to separate sleep,” notes Dr. McKenna.  Breastfeeding is associated with a lower risk of Sudden Infant Death Syndrome.

As the person charged with seeing the protocol through to fruition from writing to approval, I found the process of achieving consensus on the evidence and recommendations to be both challenging and rewarding. It required working closely with many people who held a variety of differing viewpoints and experiences on the topic and finding common ground. We are thus especially satisfied that this protocol represents the best evidence-based and practical recommendations for clinicians. We hope this protocol will be widely used.

Melissa Bartick, MD, MSc is an internist at Cambridge Health Alliance and Assistant Professor at Harvard Medical School. 

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Support for Lactating Medical Trainees

Authored by: Sarah Shubeck, MD and Megan Pesch, MD, MS

The culture of medical training and demands of residency work is often regarded as not conducive to the needs of lactating physicians. The need for “breaks” or perceived lack of dedication to workplace can lead to misperception of lactating trainees and pressures to stop milk expression before reaching an individual’s goal. Additionally, recent work has demonstrated that physician mothers struggle to meet their personal breastfeeding goals at rates higher than their peers, most often attributed to the demands of their work and lack of workplace support and infrastructure.

Those successful lactating medical trainees have squeezed in quick “pump breaks” in between patients or cases, struggled with mastitis or discomfort from extending duration between milk expression, or have experienced being reprimanded for taking time to express milk. Additionally, the lack of clean and available lactation spaces result in women turning to bathroom stalls or skipping times for expression. Despite these discouraging and humiliating encounters, many lactating medical trainees have found success through pressing on individually, but often with having to sacrifice their supply and morale and compromise their personal breastfeeding goals.

The plight of the breastfeeding medical trainee has received recent well deserved attention. Several publications, including those by Livingston-Rosanoff et al., and Pesch et al, have highlighted these difficulties and proposed protections and education around the needs of lactating physicians. This recent work highlights three key components:

• First, there is a critical need for supporting trainees to be allowed time for milk expression as determined by the trainee and her healthcare providers. For example, residents are often hesitant to ask for a “pump break,” but departmental support for milk expression times allows women residents to meet their health needs without sacrificing learning opportunities.
• Second, as required by federal mandate, medical resident employees must be provided lactation spaces that are clean, private, and close to patient care settings to minimize time away from clinical and educational opportunities. Program directors and departments can work to provide convenient and private spaces through creative use of call rooms and empty patient care settings to meet the needs of their lactating trainees.
• Finally, creating an open and supportive culture around lactation within a department and institution is essential. Workplace education of faculty, staff, and trainees and the adoption of policies and guidelines can protect and support lactating trainees can function to normalize lactation in medical training. (See Livingston-Rosanoff et al., and Pesch et al, for examples of policies and guidelines).

Supporting lactation for medical trainees is not only the right thing to do for their health and wellness, but it will almost surely have a trickle-down effect to the care they provide their breastfeeding patients.

Eliminating Disparities in Breastfeeding and Infant Mortality: Conference 2018

Although breastfeeding rates are increasing in the US, significant disparities in breastfeeding and infant mortality persist.  Cincinnati Children’s Hospital Medical Center and partners were delighted to host the “Third Annual Conference to Eliminate Disparities in Breastfeeding and Infant Mortality:  Taking Action for Equity” as a pre-Conference to the Ohio Infant Mortality Summit at the Duke Energy Convention Center in Cincinnati, Ohio.  Our Keynote speaker was the inspiring Dr. Camara Jones from Morehouse School of Medicine, who helped us critically examine how racism must be acknowledged and addressed to make inroads toward health equity.

Our First Annual Conference with Keynote speaker, Dr. Michal Young, helped us to define the problem of breastfeeding disparities and infant mortality.  The Second Annual Conference featured Keynote speaker, Dr. Kimarie Bugg, who took us deeper by addressing the role of Implicit Bias.  Our participants provided feedback, requesting to leave the next conference with Action Tools to make changes in their own communities to eliminate disparities so this year we are “Taking Action for Equity”.

To that end, our Conference this year began with an inspiring opening from City of Cincinnati Health Commissioner, Melba Moore, who challenged everyone to develop novel ways to improve community health.  From there, the conference highlighted the successful efforts of 42 speakers from around the State of Ohio and beyond, representing these programs:  CenteringPregnancy, the State of Ohio efforts to improve breastfeeding (Ohio First Steps, WIC, Ohio Department of Health), Hospital Quality Improvement, the importance of Fathers, and the amazing work of Doulas.  These programs provided the first set of Key Highlights to nearly 400 health care providers, community members, and parents, who then were able to “go deeper” in workshop formats, along with an option to learn the basics of “Breastfeeding 101.”  After lunch, attendees rejoined for a second set of Key Highlights, with representatives from Home Visitation programs, Mom-to-Mom Support groups (https://www.facebook.com/Avondale-Moms-Empowered-to-Nurse-1257926900973280/), Rural and Appalachian breastfeeding groups and Breastfeeding while Going back to Work.  These presenters also provided a deeper dive with workshop sessions, and the option for a “Breastfeeding 911” course to help front-line providers and support people troubleshoot common problems.  Each workshop provided a take home “toolkit” for attendees.

In addition to many local Cincinnati area efforts to eliminate disparities in breastfeeding, we were delighted to have experts from Cleveland, Columbus and beyond share their expertise with us.  The Doula segment was especially exciting  as co-presenter, Jessica Roach from ROOTT (Restoring Our Own Through Transformation) arrived to the conference JUST as her bio was being read, (coming, of course, from a delivery, directly to the stage!), as well as Christin Farmer, at Birthing Beautiful Communities in Cleveland who brought her “Dude-la”, Neal Hodges!  We learned about ROBE (Reaching Our Brothers Everywhere) from our local Wisdom Council Member, Calvin Williams, and Founder, Wesley Bugg, Esq., the CenteringPregnancy program in Cleveland , and so many more Ohio highlights!

Dr. Lori Winter and Dr. Julia Ware

Commissioner, Melba Moore, Dr. Camille Graham, Dr. Corinn Taylor, Dr. Karen Bankston

Dr. Camara Jones and Jamaica Gilliam

Dr. Camara Jones took us through an intensive discussion of the multiple dimensions through which racism drives health disparities using her powerful 3-dimensional cliff analogy highlighting differences in: the quality of care received within the healthcare system, access to healthcare and preventive services, and life opportunities, exposures, and stresses that result in differences in underlying health conditions.

She defines racism as “a system of structuring opportunity and assigning value based upon the social interpretation of how one looks. Racism is a system that:

1. Unfairly disadvantages some individuals and communities
2. Unfairly advantages other individuals and communities
3. Saps the strength of the whole society through the waste of human resources.

Racism has created inequities in our country. Dr. Jones helped us to see that the barriers to health equity include the narrow focus on the individual (“I am not racist, so these facts don’t apply to me or how I treat my patients!”); the fact that we are an “A-historical” culture that is disconnected from and fails to acknowledge our recent past (“Slavery ended more than a hundred and fifty years ago – why can’t you get over it?”; we don’t recognize the underlying structural system of inequity and privilege that is at the foundation of health disparities (“Why is it that a mom’s zip code is more likely to predict birth outcomes, infant survival, and breastfeeding success than her access to health care?”); and that we are instead overly focused on the myth of meritocracy – an example – two babies – equal opportunity or equal potential? (“They just aren’t trying hard enough – they could breast feed if they really wanted to!”)

Some key takeaways from Dr. Jones:

1. When you feel uncomfortable, “LEAN IN”
2. To achieve health equity we need to:
   1. Value all individuals and population equally
   2. Recognize and rectify historical injustices
   3. Provide resources according to need
3. You can learn more about Dr. Jones’ Cliff Analogy in this 5 minute video by the Urban Institute.

An added treat to the Conference was an optional learning lunch with new AAP Section on Breastfeeding Chair, Dr. Lori Feldman-Winter, who was giving a talk on Safe Sleep and Breastfeeding at a Safe Sleep Summit occurring simultaneously to our Conference!  Over 130 of our participants were able to join this event, and enjoyed the review of the evidence and guidelines for safe sleep and breastfeeding from the AAP lens.

One of the most exciting aspects of the Conference is still to come.  We will harness the energy generated from the diverse Conference presenters and attendees to continue improving breastfeeding rates in marginalized populations. It is clear that we have a wealth of talent and will need to use many different strategies to achieve this goal. Our participants are filling out a “Call to Action” survey as part of their Conference evaluation, so that we can continue to connect and collaborate in areas of interest to eliminate disparities through learning communities across the state. Stay tuned for More to Come!

Pre- and post-conference video clips:

http://www.fox19.com/video/2018/12/14/breastfeeding-disparities-challenges/

http://www.fox19.com/video/2018/12/14/breaking-down-barriers-breastfeeding/

Shared Safe Sleep and Breastfeeding Posters (unbranded) from Ohio First Steps:

www.ohiohospitals.org/OHA/media/Images/Patient%20Safety%20and%20Quality/Documents/Breastfeeding/First-Steps-2017-Feeding-Safe-Sleep-flierUNBR.pdf

www.ohiohospitals.org/OHA/media/Images/Patient%20Safety%20and%20Quality/Documents/Breastfeeding/First-Steps-2017-Spanish-Feeding-Safe-Sleep-flier.pdf

Cincinnati Children’s Conference Co-Chairs:

Julie Ware, MD, MPH, FABM and ABM Board Member

Laura Ward, MD, ABM Member

Camille Graham, MD, Executive Community Leader

 

For more information, please contact Dr. Julie Ware, julie.ware@cchmc.org

Blog posts reflect the opinions of individual authors, not ABM as a whole.

Where will you be when (not if) you fall asleep while feeding your baby?

Healthy newborns wake easily and often to feed, and a “good sleeper” in this age group is one that lets you know when he or she is hungry, is an efficient and effective feeder, and settles after the feeding and falls back asleep.  Modern societal expectations often do not allow for or encourage new mothers to sleep during the 16-20 hours/day that a newborn sleeps.  There is often housework, family and visitors, thank you notes, older siblings, and far too often at least in the U.S., an earlier-than-it-should-be return to work.  The “village” that traditionally swooped in and surrounded the dyad with care and support is often spread across miles, even oceans, and these mothers, while still recovering from birth, are left alone as their partner returns to work.  It is not surprising that new mothers find themselves exhausted and in “survival mode” during which time the recommendations that they have heard to feed a certain way or have the baby sleep a certain way may fly out the window as they desperately try to achieve a little more sleep.  And even though they may or may not be planning to, mothers of newborns are falling asleep while feeding their babies.

In addition, depending on where they turn for information, the recommendations for infant feeding and safe sleep can be confusing and may appear to be at odds with one another.  We know that mothers who bedshare with their infant breastfeed for longer.  We also know that where babies start off the night is not always where they end up in the morning.  We know that breastfeeding is protective against Sudden Infant Death Syndrome (SIDS), but also that bedsharing may pose a risk for a sleep-related infant death, particularly in the setting of other risk factors such as prenatal smoking, formula feeding, maternal substance use, sedating medications, maternal obesity, prematurity, and the presence of soft bedding in the sleep environment.  Some organizations recommend bedsharing as a means of supporting breastfeeding and cite data about the physiologic patterns and postures of mothers and babies when they bedshare.  Other recommendations focus on safe sleep and recommend breastfeeding as a strategy to reduce the risk of SIDS but recommend against bedsharing to avoid an unintended sleep-related death.

Worldwide study on sudden infant death finds factors associated with poverty and racism are more important than bedsharing

Last week, we published our novel study, “Sudden Infant Death and Social Justice: A Syndemics Approach,” showing that bedsharing – which has been the main focus of many interventions – is not the primary risk behind sudden infant death.

Instead, factors associated with poverty and racism have much more to do with Sudden Unexplained Infant Death (SUID), which includes suffocation, and its subset, SIDS (Sudden Infant Death Syndrome). Looking at populations around the world and the known risk factors for sudden infant death, we found that the vast majority of infants dying are from poor or marginalized populations, especially people who have experienced historical trauma. On the other hand, many wealthy and privileged populations have high rates to moderate rates of bedsharing,like Asian Americans and Swedes, yet have some of the lowest rates of SUID/SIDS in the world.

We used the medical anthropological theory of syndemics to help explain how social inequities that may be driven by historical forces and their legacies lead to the clustering of these risk factors, which ultimately results in higher death rates in poor and marginalized populations. It is important to view SUID/SIDS in the greater context of the growing field of social determinants of health.